Research Institute of the McGill University Hospital, Gastroenterology, Montreal, Canada

Background

Video capsule endoscopy (VCE), a non-invasive and accurate diagnostic modality for the evaluation of small bowel mucosal disorders, is increasingly performed in elderly patients. Crohn’s disease (CD) typically afflicts young patients, with a peak incidence in the second and third decades. Less than 5% of CD is diagnosed after the age of 70. No report was found of CD diagnosed in elderly patients by VCE following negative upper and lower gastrointestinal tract (GI) endoscopies (‘obscure’ CD). The aim is to report our experience of newly diagnosed CD by VCE in elderly patients.

Methods

Retrospective observational study on all VCE performed in elderly patients (aged ≥70) at a tertiary hospital between January 2010 and September 2015. All patients had prior negative bidirectional GI endoscopies. Patients with known IBD were excluded. The diagnosis of small bowel CD was based on consistent endoscopic findings, exclusion of other potential causes of small bowel inflammation such as infections, celiac disease, or drugs (NSAIDs, olmesartan, methotrexate, mycophenoltate, etc) in the previous month. Criteria also included a Lewis endoscopic severity score of >790 (moderate-to-severe inflammation) or histological confirmation for those with lower Lewis score (350–790; normal < 135).

Results

For elderly patients, 207 VCE were performed during this period (median age 77, range 70–93, 51% M): 8 patients (3.9%), age 70–87 (median 72, 75% F) were diagnosed with small bowel CD based on the aforementioned criteria. Reason for referral for VCE was iron deficiency anaemia (IDA) or obscure GI bleed (OGIB) for 50% of CD patients, and 25% each had unexplained chronic abdominal pain/diarrhoea or ankylosing spondylitis without GI symptoms that were referred to exclude concurrent CD. Over 95% of the 199 non-CD patients were referred for OGIB or IDA. An elevated faecal calprotectin level (> 600) was found in 4 out of 5 CD patients tested before VCE; 1 had a negative result (< 50µg/g). None of the CD patients had significantly elevated C-reactive protein. No CD cases had capsule retention. Further, 1 non-CD patient had capsule retention secondary to NSAID induced stricture, requiring surgery. The detection of small bowel CD by VCE led to a change in management for 5/8 cases (budesonide / methotrexate / adalimumab). Follow-up was unavailable for the other 3 cases.

Conclusion

VCE can be safely performed in the elderly. A proportion of these patients may have unanticipated small bowel CD despite negative bidirectional GI endoscopy. Faecal calprotectin may serve as a potential predictive biomarker in this setting. Detection of obscure CD led to a change in management in the majority of cases.